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Team-Based Transition Management- A Hospital Discharge Follow Up ProcessPRESENTERS:
ANDREW ATKINS
DIANA NICHOL
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Conflict of Interest Statement
We do not have any relationships with financial sponsors
We do not have any conflicts of interest and therefore no bias
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Who are we…?Andrew AtkinsQuality Improvement Decision Support Specialist (QIDSS) ESC LHIN-1 FHTs
Something interesting about me:I’m getting married next week
Diana NicholQuality Improvement and Effective Transitions Lead at TDFHTRegistered NurseMember, HQO Transitions from Hospital to Home Advisory Standards CommitteeSomething interesting about me: I enjoy reading books about theories of the universe
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Hospital Discharge Follow Up Trailer
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What We Hope You Will Take Away from Today1. Implement a patient centered , team-based approach to managing patient
transitions from hospital to home in a primary care setting
2. Capture and identify all hospital discharged patients using your EMR
3. Have a meaningful and effective follow up with all in-patient discharges within 7 days (no triaging, no eligibilities)
4. Use your team to increase capacity in effectively managing patient transitions
5. Use additional modules with your process depending on available resources and team focus
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QIP Priority Indicator
7-day Post Discharge Follow Up (any provider)
“Number of Hospital Discharges (any condition) where timely (within 48 hours) notification was received, for which follow-up was done (by any mode, any
clinician) within 7 days of discharge”
- HQO indicator Library
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Who’s in our audience today?How many people currently have no structured process in place?
Have a process that you want to improve?
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TDFHT Old Hospital Discharge Process
• Administrative staff receive hospital discharge patient list from Transform Physician Portal daily
Gathering Information
• Administration calls patients and books them in for a follow up appointment with their Primary Care Provider
Follow Up Booked
• Fill out an excel spreadsheet with the following information
DOCUMENTATIONPatient Name (last, first)
DOBAge
Date AdmittedDate DischargedHospital Name
DiagnosisCMG
TDFHT appointmentDischarge status
Patient readmitted in 30 days?Primary care provider
Comments
Barriers & Gaps Identified
1. Lost Opportunity for:• Clinical assessment • Triaging• Gathering holistic information and
documented in most appropriate location (EMR)
• Clinical action on identified health concerns access difficulties
• Updating the EMR
2. Only captured CKHA discharged patients
(Missed: all other hospitals)
3. Information only lives in the Excel Spreadsheet and not shared or documented in EMR
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Why did we change?Intensive case management program success supporting only a certain populations through transitions in care from hospital to home
Identified that all patients experiencing transitions could benefit from this model of care
There were similar themes identified in helping patients through transitions such as:
1. Patients unsure who to contact with questions or concerns2. Medication list discrepancies3. Under utilization of primary care post discharge resulting in inappropriate
visits to ER or readmissions4. Wasted time during follow up appointments searching for information
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“Our Story” – illustrated by Data
• Struggles of the old process• Ups and Downs of the new process
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New Responsibilities -August 2018
Nurse Training–January 2018
Nurse Training–September 2018
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Internal Assessment & GoalsInternal Assessment Goals Misalignments
Questions to consider:1. Who’s on my team? Do we
have a committee for this project?
2. How big is my team? 3. What are we already doing?
(taking a patient journey, and document trail)
4. Understanding patient roster/population/needs (using your EMR)
5. # discharges/month 6. What kind of education do we
need? 7. What type of technology do
we have? (HRM, EMR) 8. Who will be a part of the process?
Items to consider:1. Using your internal
assessment, calculate resources expected to accomplish the goal you set.
2. What do you want to accomplish? (are you only following up with patients from one hospital? Do you want to expand to all hospitals?)
3. All patients? Inpatient? ED? All hospitals? One hospital?
4. Only certain conditions?5. Do we want to have
additional modules? (screening, med rec)
Internal Assessment vs. Goals
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TDFHT Internal AssessmentResources Patient
PopulationTechnology Education Current Process Demand
6 RPNs3 RNs2 Diabetes educators1 CHF/COPD educator2 social workers8 PCP’s
13,400 rostered
47.5% >50 y/o
Rural
What we have:HRM
Accuro
Faxes go to one clerical person who index's them
Clinical Connect
What we have:
Case management
Healthcare navigation
Book CKHA discharged patients in for follow up appointment only done by clerical
50-80 follow ups/ month
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Where do our patients live?
Windsor-Essex
Chatham- Kent
Sarnia-Lambton
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The *New* Hospital Discharge Follow-up Process1. Modular design to accommodate any team
2. Specifically designed to be shared
3. Currently has been shared with the FHTs within our LHIN
4. Accommodates different populations, resources and demographics
5. Teams can pick and choose which module works for them
6. Patient centered
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The Core Module – Hospital Discharge Follow Up Phone Call
1. Tools
2. Identify
3. Track & Delegate
4. Chart Review
5. Making the Phone Call
6. Action
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Core Module- Tools
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Core Module – Identifying Discharges1. Query/ Searches done every morning (Mon-Sat)
2. Physician/Document Tasking on LHSC and other hospitals we do not receive notification from
3. Data Quality Assurance query run every Friday
4. Physician Portal (validation)
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Core Module - Tracking Discharge Follow UpsExcel Template EMR Task
PROS• One space for multiple nurses to access• Can colour code• Can visualize all past and upcoming follow ups
CONS• Does not document all actions in EMR• Reworking/ Double documenting• All discharged patient information in one document
(privacy)
PROS• Documents patient discharge identify date and all
follow up actions in their EMR• Secure
CONS• Deletes task immediately once it is completed, difficult
to trace back if you forgot something• Not for the visual person• Difficult to do quick daily audits on patients followed
up by others
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Core Module – Chart Review1. Brief chart review to become familiar with the patient’s story relevant to the
admission
2. Review previous admissions of similar or same complaint to piece together the patient’s struggles
3. Gather sources for med rec if you will be implementing that module
4. Updating EMR during chart review
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Core Module– Making the phone call1. The opening statement
2. Script templates
3. Using the “Hospital Discharge Follow Up Form” as a guideline for your conversation
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Core Module – Action1. Action upon every abnormal finding
2. Sharing your assessment amongst your team and beyond
3. Booking and coordinating appointments
4. Ensuring patients don’t fall through the cracks
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Additional Modules Each additional module you can choose from to add to your Hospital Discharge Follow Up Process
You can always add or remove these modules depending on available resources or change In demands
Modules depending on focus of the team or QIP
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Module 1 - Medication Reconciliation
1. 3 que’s for a med rec
2. The Med Rec team: RNs, RPNs, Pharmacist, PCPs
3. Multiple Medication List Sources
4. Sharing the med rec
5. Collecting med rec data Med Rex
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New Med Rec Process Map
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Module 2 – Malnutrition Screening
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Malnutrition Screener in EMR
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Module 3 : Case Management1. Assessment and
continuity of care2. Information sharing3. Coordinated Care
plans
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Module 4 - Internal/External referrals
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What patients are provided with from discharge to follow UpHealth teaching/ Health education
Healthcare navigation
Internal/External program/service navigation and/or referral
Ensure accessibility/transportation
Direct nurse contact during business hours
EMR update
Medication reconciliation (if applicable)
Malnutrition screener
Urgent care hours and utilization reviewed
Reminder to bring medications to appointment
Collaboration among their TDFHT circle of care and sometimes LHIN home care
Immediate needs met
A mode of follow up regardless if they are able to see their PCP
Coordinate all their TDFHT appointments to accommodate accessibility, and effectiveness
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What the team is provided with for the follow-up appointmentOverview of patient’s current state since being discharged home
Medication list up to date
Awareness of current community services that are part of the patient’s circle of care
A more personal view of the patient
Updated diagnostic/ problem list
Surgery/Procedure list up to date
Dates of follow up appointments for referrals made in acute care
One page focused summary of the patient’s admission
Ability to focus follow up appointments more on recommendations and patient’s requests.
Reduced amount of time searching for pertinent information
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Success Stories
"When you called I felt like thank god, someone from the doctors office knows everything that is going on with both of my parents. When you came on board everything fell in place, after the first hospital visit everything was a
mess“-KM